My name is Brendan Shee, I'm a third-year resident at UCLA. I'll be discussing the impact of graft choice on return-to-support testing after adolescent ACL reconstruction. We have nothing to disclose. The number of ACL reconstructions performed for pediatric adolescent population continues to rise. There's no consensus on the best autograft option. Hamstring tendon is the most commonly used. There are low rates of donor site morbidity. Bone patellar tendon bone grafts, they've been associated with better return-to-support rates, better post-op flexion strength, and lower rates of graft rupture compared to hamstring autograft, but there are higher rates of anterior knee pain. There's a sparse amount of data on bone quadriceps tendon use in the adolescent population, but some studies in the adult population have demonstrated similar return-to-support and strength rates compared to bone patellar bone, with better strength and better re-rupture rates compared to hamstring tendon. When assessing ACL reconstruction outcomes, there's a few measures. First is graft survival, re-rupture rate. Second is patient-reported outcomes, donor site pain, overall patient experience, and the third is functional ability and the ability of the patient to return to support in a quick manner. Return-to-support assessments provide objective data for clinicians to use to determine if their patients are ready to go back to their sport, incorporate strength testing, balance testing, and hop testing. This is a study from 2019 looking at adult patients undergoing ACL reconstruction comparing bone quadriceps tendon and bone patellar tendon bone with 15 per group, finding that there was no difference in extensor strength or functional outcomes in terms of hop tests and step length asymmetry when comparing these two autograft types. Despite this, there's no studies that are looking specifically at the adolescent population and one limitation of this study is it's relatively underpowered. So our study question was, at a minimum of 6 months post-op, is there a difference in return-to-support assessment performance between adolescent ACL patients receiving hamstring, BTB, or bone quad tendon autographs? This is a single institution retrospective review from 2016 to 2020. We included all primary ACL reconstructions utilizing quad hamstring or BTB autographs in patients 19 years or younger. Here are our exclusion criteria. All RTS assessments were performed by trained physical therapists at a minimum of 6 months post-op. Graft choice was determined in a shared decision-making model between the surgeon, the patient, and family with discussion of skeletal maturity and potential donor site complications. All patients underwent the same standard post-op protocol dependent on the presence of a meniscus repair and physical therapy was ordered to start within one week of surgery. Patients were followed for up to 52 weeks. At a minimum of 6 months when the physical therapist felt the patient was ready to return to sport, they performed a battery of return-to-sport testing. The goal for clearance was a limb symmetry index of greater than 90% on all tests, which included isometric strength testing, single leg balance testing, and hop testing. Our study included 105 patients in total, ages 10 to 19. The mean time to their first RTS assessment was 9 months, and the mean time to clearance for sport was 12 months. Looking at our data, the majority of our patients did receive hamstring autographs. These patients were also younger on average. A lower proportion of BTB patients underwent concomitant meniscus repair, and the days to first RTS evaluation was significantly higher in patients undergoing BTB autographed. When looking at their performance on their first RTS assessment, patients that underwent a hamstring autograph had significantly lower absolute hamstring strength and also significantly poorer hamstring strength on their operative side compared to the non-operative side when compared to BTB or BQT autographed groups. There was no significant difference in their quadriceps absolute strength or symmetry, and there was also no significant difference in the other muscles tested, including the glutes adductors, and there was no significant difference in the performance on balance or hop tests. When looking at clearance rates within one year, patients that underwent hamstring autografting, they were only cleared at a rate of about 40% within one year, which was significantly lower than the BTB or the BQT autographed groups. No other variables, including age, sex, time to their first RTS assessment, number of PT sessions, or the presence or type of meniscus surgery were associated with clearance within one year. On multivariate analysis, it confirmed hamstring graft use was associated with lower odds of clearance at one year when compared to both BQT and BTB autographs. There's no significant difference in clearance rates between BQT and BTB autographs. So in conclusion, patients undergoing ACL reconstruction that received BQT or BTB autographs demonstrated similar performance on RTS assessments, whereas hamstring autographed patients had worse strength and symmetry at their first RTS assessment and were less likely to be cleared for sport at one year. Meniscus repair did not affect RTS performance or clearance rates. Future directions include increasing our sample size so we can perform subgroup analysis by skeletal maturity, comparing our RTS outcomes to PROs, assessing the instance of an anterior knee pain between graft types, and longer follow-up for complications and failures. Thank you very much.

graft choice

return-to-sport testing

adolescent ACL reconstruction

autograft options

hamstring tendon